Loading...

FACIAL INTAKE FORM AND CONSENT TO FACIAL TREATMENTS BY EMILY LETOURNEAU AT TREAT LLC

I understand that esthetics and skincare therapy cannot cure, treat, prevent, or diagnose any medical condition. The services provided by Emily LeTourneau at Treat LLC are intended to improve skin appearance and overall wellness. Any information exchanged during services is provided at my own discretion. All personal information disclosed in the Facial Intake Form or during services will remain confidential.

I acknowledge that certain esthetic treatments may be contraindicated under specific medical conditions. I affirm that I have disclosed all known medical conditions that may affect the skincare treatments provided by Emily LeTourneau at Treat LLC. I agree to update Emily LeTourneau prior to future sessions regarding any changes in my health. I understand that Emily LeTourneau and Treat LLC are not liable for any adverse effects should I fail to provide updated health information.

I fully understand that the services provided fall within the scope of esthetics and involve non-medical skincare treatments and therapies.

Cancellation and Reschedule Policy

I understand that Emily LeTourneau at Treat LLC requires at least 24 hours’ notice to cancel or reschedule an appointment. Failure to provide sufficient notice may result in a cancellation fee of up to $50.

Notice of Photo and Video Usage

I understand that Emily LeTourneau may request to take photos or videos to document treatment progress, showcase before-and-after results, or for internal records. With my consent, these images may also be used for marketing purposes by Emily LeTourneau.

If I do not consent to external use of my photos/videos, I will tell Emily LeTourneau prior to the start of the skin care service. 

Release of Liability and Consent to Facial Treatments

I acknowledge that the services I receive, and their potential risks, have been explained to me verbally and/or in writing. I understand and accept these risks, including but not limited to the inherent risks of esthetic treatments and potential exposure to infectious diseases.

By signing this waiver, I hereby release, waive, and discharge Emily LeTourneau and Treat LLC from any and all claims, liabilities, or damages, including but not limited to personal injury or adverse reactions, arising directly or indirectly from the services provided or products used.


First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Health and Medical History
Do you currently have active acne? *
No
Yes
Have you ever had a cold sore? *
No
Yes
Are you currently trying to concieve, pregnant or breastfeeding? *
No
Yes
Are you currently experiencing or have you been diagnosed with any of the following conditions, which may be contraindicated for lymphatic drainage treatments: urinary system infection, Crohn’s disease, hyperthyroidism, deep venous thrombosis, or lymphedema? A “Yes” response does not prevent you from receiving facial treatments, but certain services may need to be modified for your safety.*
No
Yes
Do you have any allergies to the following?
Nuts
Seaweed, Shellfish, Seafood
Asprin or Salicylic Acid
Topical Anesthetic's (like lidocaine, benzocaine ect)
Metal
Fruit
In the last 2 weeks, have you had any of the following procedures or used any of the following active products in the area to be treated?
Botox or Fillers
Tretinoin or Prescription Vitamin A Exfoliants
Antibiotics (topical or oral)
Hydroquinone
Adapalene
Blood Thinners
Antifugal
Antiviral
What would you like to focus on in your facial treatment? Check all that may apply.
Dry, flaky or dehydration
Redness, Rosacea or veins
Acne, clogged pores
Scaring and/or texture
Skin tone, pigmentation, dark spots and/or sun damage
Anti-aging, wrinkles, fine lines
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!